Care and Management of Multiple Pregnancy

Management of multiple pregnancy:

Specific management for multiple pregnancy will be determined by your physician or midwife based on:

Your pregnancy, overall health, and medical history

The number of fetuses

Your tolerance for specific medications, procedures, or therapies

Expectations for the course of the pregnancy

Your opinion or preference

Management of multiple pregnancy may include the following:

Increased nutritionMothers carrying two or more fetuses need more calories, protein, and other nutrients, including iron. Higher weight gain is also recommended for multiple pregnancy. The Institute of Medicine recommends that women carrying twins who have a normal body mass index should gain between 37 and 54 pounds. Those who are overweight should gain 31-50 pounds; and obese women should gain 25-42 pounds.

More frequent prenatal visitsMultiple pregnancy increases the risk for complications. More frequent visits may help detect complications early enough for effective treatment or management. The mother's nutritional status and weight should also be monitored more closely.

ReferralsReferral to a maternal-fetal medicine specialist, called a perinatologist, for special testing or ultrasound evaluations, and to coordinate care of complications, may be necessary.

Increased restSome women may also need bedrest--either at home or in the hospital depending on pregnancy complications or the number of fetuses. Higher-order multiple pregnancies often require bedrest beginning in the middle of the second trimester. Preventive bed rest has not been shown to prevent preterm birth in multiple pregnancy.

Maternal and fetal testingTesting may be needed to monitor the health of the fetuses, especially if there are pregnancy complications.

Tocolytic medicationsTocolytic medications may be given, if preterm labor occurs, to help slow or stop contractions. These may be given orally, in an injection, or intravenously. Tocolytic medications often used include magnesium sulfate.

Corticosteroid medicationsCorticosteroid medications may be given to help mature the lungs of the fetus. Lung immaturity is a major problem of premature babies.

Cervical cerclageCerclage (a procedure used to suture the cervical opening) is used for women with an incompetent cervix. This is a condition in which the cervix is physically weak and unable to stay closed during pregnancy. Some women with higher-order multiples may require cerclage in early pregnancy.

How are multiple pregnancies delivered?

Delivery of multiples depends on many factors including the fetal positions, gestational age, and health of mother and fetuses. Generally, in twins, if both fetuses are in the vertex (head-down) position and there are no other complications, a vaginal delivery is possible. If the first fetus is vertex, but the second is not, the first fetus may be delivered vaginally, then the second is either turned to the vertex position or delivered breech (buttocks are presented first). These procedures can increase the risk for problems such as prolapsed cord (when the cord slips down through the cervical opening). Emergency cesarean birth of the second fetus may be needed. Usually, if the first fetus is not vertex, both babies are delivered by cesarean. Most triplets and other higher-order multiples are born by cesarean.

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Vaginal delivery may take place in an operating room because of the greater risks for complications during birth and the need for cesarean delivery. Cesarean delivery is usually needed for fetuses that are in abnormal positions, for certain medical conditions of the mother, and for fetal distress.